Primary Care In India Research Articles

Physician and patient concordance of report of tobacco cessation intervention in primary care in India.

BackgroundTobacco cessation interventions by physicians hold promise in improving quit rates. The 5As intervention (‘Ask’, ‘Advise’, ‘Assess’, ‘Assist’ and ‘Arrange’) is an evidence-based approach for tobacco cessation. However, little is known about adherence with the tobacco cessation interventions in primary care in India. In the present study we assessed physicians’ adherence with the 5As intervention and explored physician and patient concordance on the report of 5As intervention for tobacco cessation.MethodsWe used data from two cross-sectional surveys conducted in 12 districts of Andhra Pradesh and Gujarat in India. The surveys were administered simultaneously to both patients attending, and physicians working in health facilities providing primary care. Health facilities were selected by systematic random sampling and patients were recruited by simple random sampling. Common health facilities where both surveys were performed were identified, and individual patients were matched to their physicians through a unique matching code to obtain the two study samples.ResultsSlight agreement was observed between the physician and patient responses on ‘Ask’ and ‘Arrange’ component of the 5As intervention. The ‘Advise’, ‘Assess’ and ‘Assist’ components showed low agreement. Slightly higher levels of agreement were seen on all components of the 5As, except ‘Advise’, for those patients who had made an attempt to quit.ConclusionsOur study suggests an urgent need for revising current strategies in order to strengthen the ‘Advise’, ‘Assess’, and ‘Assist’ interventions in tobacco cessation in primary care settings. Patient surveys should be used routinely in assessing fidelity and provider adherence for large scale behavioral health programs.

The development of mental health services within primary care in India: learning from oral history.

BackgroundIn India very few of those who need mental health care receive it, despite efforts of the 1982 National Mental Health Programme and its district-level component the District Mental Health Programme (DMHP) to improve mental health care coverage.AimsTo explore and unpack the political, cultural and other historical reasons for the DMHP’s failures and successes since 1947 (post-independence era), which may highlight issues for today’s current primary mental health care policy and programme.MethodsOral history interviews and documentary sourcing were conducted in 2010–11 with policy makers, programme managers and observers who had been active in the creation of the NMHP and DMHP.ResultsThe results suggest that the widely held perception that the DMHP has failed is not entirely justified, insofar that major hurdles to the implementation of the plan have impacted on mental health coverage in primary care, rather than faults with the plan itself. These hurdles have been political neglect, inadequate leadership at central, state and district levels, inaccessible funding and improperly implemented delivery of services (including poor training, motivation and retention of staff) at district and community levels.ConclusionAt this important juncture as the 12th Five Year Plan is in preparation, this historical paper suggests that though the model may be improved, the most important changes would be to encourage central and state governments to implement better technical support, access to funds and to rethink the programme leadership at national, state and district levels.

The global dissemination of psychological treatments: a road map for research and practice.

The global dissemination of psychological treatments: a road map for research and practice.

The effectiveness and cost-effectiveness of lay counsellor-delivered psychological treatments for harmful and dependent drinking and moderate to severe depression in primary care in India: PREMIUM study protocol for randomized controlled trials

BackgroundThe leading mental health causes of the global burden of disease are depression in women and alcohol use disorders in men. A major hurdle to the implementation of evidence-based psychological treatments in primary care in developing countries is the non-availability of skilled human resources. The aim of these trials is to evaluate the effectiveness and cost-effectiveness of two psychological treatments developed for the treatment of depression and alcohol use disorders in primary care in India.Methods/designThis study protocol is for parallel group, randomized controlled trials (Healthy Activity Program for moderate to severe depression, Counselling for Alcohol Problems for harmful and dependent drinking) in eight primary health centres in Goa, India. Adult primary care attendees will be screened with the Patient Health Questionnaire for depression and, in men only, the Alcohol Use Disorders Identification Test for drinking problems. Screen-positive attendees will be invited to participate; men who screen positive for both disorders will be invited to participate in the Counselling for Alcohol Problems trial. Those who consent will be allocated in a 1:1 ratio to receive either the respective psychological treatment plus enhanced usual care or enhanced usual care only using a computer generated allocation sequence, stratified by primary health centre and, for depression, by sex. The enhanced usual care comprises providing primary health centre doctors with contextualized World Health Organization guidelines and screening results. Psychological treatments will be delivered by lay counsellors, over a maximum period of three months. Primary outcomes are severity of disorder and remission rates at three months post-enrolment and, for the Counselling for Alcohol Problems trial, drinking and the impact of drinking on daily lives. Secondary outcomes include severity of disorder and remission rates at 12 months, disability scores, suicidal behaviour and economic impact, and cost-effectiveness at three and 12 months. 500 participants with depression and 400 participants with harmful drinking will be recruited. Primary analyses will be intention-to-treat.DiscussionThese trials may offer a new approach for the treatment of moderate-severe depression and drinking problems in primary care that is potentially scalable as it relies on delivery by a single pool of lay counsellors.Trial registrationBoth trials are registered with the International Society for the Registration of Clinical Trials (Healthy Activity Programme registration number ISRCTN95149997; Counselling for Alcohol Problems registration number ISRCTN76465238).

1(st) National Conference on Family Medicine and Primary Care: A Journey Toward Stronger Primary Care in India.

Academy of Family Physicians of India organized the first National Conference on Family Medicine and Primary Care (FMPC) on 20-21 April 2013 at India International Centre New Delhi. The conference was a major success towards positioning of requirement for a distinct academic discipline (family medicine) within the medical and nursing education system as a means for strengthening of primary care in India. The event gained its prominence in the times when universal health coverage is being debated. A generalist approach in development of human resource prominently figured in the discussions. The deliberations and talks of the Indian as well as international experts were recorded and released as the report of national consultation on family medicine programme.

Cultural aspects of primary healthcare in india: A case- based analysis

Delivering quality primary care to large populations is always challenging, and that is certainly the case in India. While the sheer magnitude of patients can create difficulties, not all challenges are about logistics. Sometimes patient health-seeking behaviour leads to delays in obtaining medical help for reasons that have more to do with culture, social practice and religious belief. When primary care is accessed via busy state-run outpatient departments there is often little time for the physician to investigate causes behind a patient's condition, and these factors can adversely affect patient outcomes. We consider the case of a woman with somatic symptoms seemingly triggered by psychological stresses associated with social norms and familial cultural expectations. These expectations conflict with her personal and professional aspirations, and although she eventually receives psychiatric help and her problems are addressed, initially, psycho-social factors underlying her condition posed a hurdle in terms of accessing appropriate medical care. While for many people culture, belief and social norms exert a stabilising, positive influence, in situations where someone's personal expectations differ significantly from accepted social norms, individual autonomy can be directly challenged, and in which case, something has to give. The result of such challenges can negatively impact on health and well-being, and for patients with immature defence mechanisms for dealing with inner conflict, such an experience can be damaging and ensuing somatic disturbances are often difficult to treat. Patients with culture-bound symptoms are not uncommon within primary care in India or in other Asian countries and communities. We argue that such cases need to be properly understood if satisfactory patient outcomes are to be achieved. While some causes are structural, having to do with how healthcare is accessed and delivered, others are about cultural values, social practices and beliefs. We note how some young adult women are adversely affected and discuss some of the ethical issues that arise.

Development of standard therapeutic guidelines for selected common diseases for the primary health care centres of a South Indian district

Abstract Method A questionnaire survey of medical officers was conducted to collect data on the most commonly-presenting diseases and doctors' treatment choices in PHCs in Mysore. Draft guidelines were developed for these conditions based on available literature, together with microbiological sensitivity data from the three district hospitals. User feedback on the draft guidelines and on guidelines in general was obtained from medical officers using a postal questionnaire. Objective To develop standard therapeutic guidelines for selected common diseases for the primary health care centres (PHCs) of a South Indian district and to evaluate medical officers' perceptions about the proposed guidelines and about guidelines in general. Setting Sample of 17 of the 93 PHCs in Mysore. Key findings Upper respiratory tract infection was the most commonly-presenting condition. Procaine penicillin was the most commonly-used drug and there were examples of inappropriate treatment choices. The survey produced evidence that access to medicines on the government's “essential” list was not uniform, with many patients having to purchase prescribed drugs that were not on the list. The response rate to the user feedback questionnaire was 62 per cent (31 doctors). The medical officers had positive opinions about guidelines in general and felt that the guidelines we proposed were useful and would help them to improve their prescribing habits. Conclusions Prescribing in primary care in India needs to be improved. The involvement of potential users of the guidelines in their development should increase their acceptability and thus their use in practice.

Common mental disorders in primary care in India: little to distinguish five commonly used screening instruments

Common mental disorders in primary care in India: little to distinguish five commonly used screening instruments

Secondary prevention of coronary artery disease in urban Indian primary care

Background Although secondary prevention has the potential to substantially reduce the risk of coronary events, its impact depends on the extent to which it is applied in the community. Presently, there is no information on the frequency with which drugs recommended for secondary prevention of CAD are used in the setting of primary care in India or other developing countries. Such information could help focus attention of physicians on its importance. Method In a prospective epidemiologic survey, 134 primary care physicians from 50 randomly selected cities distributed throughout India identified outpatients with stable CAD and symptoms of angina. Demographic and clinical characteristics, together with their treatment were recorded on a standardized questionnaire. Results In 406 patients, the number (%, 95% CI) receiving aspirin was, 335 (82.5, 78.2 to 86.2); b-blockers, 215 (53.0, 48.1 to 57.9); angiotensin converting enzyme inhibitors (ACEI), 63 (15.5, 12.0 to 19.0); and statins, 280 (69.0, 61.0 to 77.0). Hypertension was untreated in 125 patients (33.4, 28.6 to 38.2). Combination treatment with any two (of aspirin, b-blocker, statin, ACEI, or antihypertensive agent other than b-blocker and ACEI) was received by 249 patients (61.3, 51.3 to 71.3); and with any three by 21 (5.2, 3.0 to 7.3). Discussion Secondary prevention is under utilized in Indian patents with CAD. Against the background of an emerging epidemic, physicians in primary care need to increase the use of widely available specific secondary preventive agents recommended by guidelines.

Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires

Screening of patients for common mental disorders (CMDs) is needed in primary-care management programmes. This study aimed to compare the screening properties of five widely used questionnaires. Adult attenders in five primary-care settings in India were recruited through systematic sampling. Four questionnaires were administered, in pairs, in random order to participants: the General Health Questionnaire (GHQ, 12 items); the Primary Health Questionnaire (PHQ, nine items); the Kessler Psychological Distress Scale (K10, 10 items), and from which we could extract the score of the shorter 6-item K6; and the Self-Reporting Questionnaire (SRQ, 20 items). All participants were interviewed with a structured lay diagnostic interview, the Revised Clinical Interview Schedule (CIS-R). Complete data were available for 598 participants (participation rate 99.3%). All five questionnaires showed moderate to high discriminating ability; the GHQ and SRQ showed the best results. All five showed moderate to high degrees of correlation with one another, the poorest being between the two shortest questionnaires, K6 and PHQ. All five had relatively good internal consistency. However, the positive predictive value (PPV) of the questionnaires compared with the diagnostic interview ranged from 51% to 77% at the optimal cut-off scores. There is little difference in the ability of these questionnaires to identify cases accurately, but none showed high PPVs without a considerable compromise on sensitivity. Hence, the choice of an optimum cut-off score that yields the best balance between sensitivity and PPV may need to be tailored to individual settings, with a higher cut-off being recommended in resource-limited primary-care settings.

Somatic and psychological models of common mental disorder in primary care in India.

Primary care attenders with a common mental disorder (CMD) frequently present with somatic symptoms. This study aimed to examine somatic and psychological models of CMD in primary care attenders in India. Cross-sectional survey of attenders at two primary care clinics. Psychiatric caseness was determined on three criteria: standardized psychiatric interview (biomedical criterion), patients' self-assessment of emotional disorder (emic criterion) and health care provider diagnosis. The GHQ-12 and the PPQ, which emphasize psychological and somatic symptoms respectively, were used as screening instruments. Although somatic symptoms were the presenting complaints for 97% of subjects, 51% of subjects with a biomedically defined CMD had a psychological illness attribution. Patients with psychological attributions were more likely to be women, to have a longer duration of illness, to have higher CISR scores and were more likely to be recognized by the primary health care (PHC) physician. The GHQ-12 was superior to the PPQ in identifying cases of CMD against the biomedical criterion for both psychologizers and somatizers; both instruments performed equally well against the emic and care provider criteria. Psychological models may be acquired by patients as CMD becomes more chronic or severe, making them more likely to be detected by PHC physicians. Psychological symptoms are superior to somatic symptoms in detecting CMD. Shorter versions of the GHQ have comparable discriminating abilities to the 12-item version and offer the practical advantage of brevity, which may make them more acceptable to PHC physicians as a clinical screening tool.